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ASSOCIATES IN PRIMARY CARE MEDICINE, INC.
An Annual Wellness Visit at our facility is not a regular office visit. It is a special office visit where the goal is to be sure we understand your special needs and
assess your health maintenance status to be sure you receive the right care and resources. Please complete this questionnaire before your visit so we can make
the most of this visit. Please understand that this is NOT to address new problems nor to provide routine care for chronic problems, provide medication refills, or
to check routine lab studies. Those issues are addressed at a separate regular office visit. We are providing you a list of your medications from our file. Please
update the list and bring it to your wellness visit. Please include all of the vitamins, supplements, and other OTC (over the counter) medications that you take.
Please update this list as well and bring it to your appointment. Please arrive at least 15 minutes before your scheduled appointment time. Thank you.
PATIENT NAME: ____________________________ DOB: ________________
APPOINTMENT DATE AND TIME: ______________________________________
Please circle your answers
Home Environment: Private home, Assisted Living, Other: _________________________________
Diet and Nutrition:
healthy diet ,
diet is high in salt ,
high caloric intake ,
high carbohydrate meals ,
___________________________________________
Fracture Risk:
fractures ,
no history of fractures ,
no previous musculoskeletal injuries ,
diet is high in fat, low in fiber ,
low calcium intake Additional Notes:
no recent explained fracture ,
history of fractures ,
sudden unexplained fractures ,
previous musculoskeletal injuries
Additional Notes: ____________________________________________________________
no sudden unexplained
recent explained fracture ,
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Physical Activity:
exercises on a regular basis ,
physical condition ,
does not exercise on a regular basis ,
physical condition ,
deconditioned due to sedentary lifestyle
recent increase in physical activity ,
good
decreased physical activity ,
poor
Additional Notes: __________________________________
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Mental Status:
never feels sad, empty, or tearful ,
significant changes in weight ,
energy ,
energy ,
no loss of interest in activities ,
no sleep disturbances or insomnia ,
no feelings of worthlessness or guilt ,
significant changes in weight ,
sleep disturbances or insomnia ,
Orientation:
loss of interest in activities ,
agitated ,
thoughts of suicide ,
loss of
history of mood disorders ,
no disorientation to date ,
disorientation to time ,
disorientation to date ,
_______________________________________________
no decreased concentrating ability ,
does not forget words ,
decreased concentrating ability ,
words Additional Notes: _________________________
Speech/Motor difficulties:
no history of depression ,
Additional Notes: ____________________________________
no disorientation to time ,
Concentration and Memory:
no loss of
no thoughts of suicide ,
feels sad, empty, or tearful ,
history of depression
no disorientation to place ,
disorientation to place
Additional Notes:
no memory lapses or loss ,
memory lapses or loss ,
no speech difficulties ,
no difficulty with fine manipulative tasks ,
time ,
no agitation ,
no history of mood disorders ,
feelings of worthlessness or guilt ,
no
forgetting
no difficulty expressing formulated concepts ,
no difficulty writing/copying ,
does not knock things over when trying to pick them up ,
speech difficulties ,
no slowed reaction
difficulty
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expressing formulated concepts ,
difficulty with fine manipulative tasks ,
slowed reaction time ,
_________________________________
difficulty writing/copying ,
knocking things over when trying to pick them up Additional Notes:
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Hearing:
no loss of hearing ,
fluctuating ,
loss of hearing in one ear only ,
getting progressively worse ,
requires TV, radio at high volume ,
loss of hearing: in both ears ,
difficulty hearing over background noise ,
tone deafness ,
Additional Notes: _______________________________________________
Vision:
no vision problems ,
worse with distance ,
images with fatigue ,
total vision loss ,
worse both distance and near ,
blind spot(s) ,
briefly vision loss ,
worse near ,
sudden partial vison loss ,
increased sensitivity to glare ,
blurred vision
worsening ,
difficulty seeing in bright light ,
seeing double
slow partial vision loss ,
worsening depth perception ,
Additional Notes: ________________________
Activities of Daily Living:
able to bathe with limited or no assistance ,
able to dress with limited or no assistance ,
to get out of chair or bed with limited or no assistance ,
toilet with limited or no assistance ,
able to feed self with limited or no assistance ,
able to groom with limited or no assistance ,
unable to bathe without assistance ,
unable to control urination and bowels ,
able to control urination and bowels ,
able to
unable to dress without assistance ,
unable to feed self without assistance ,
of chair or bed without assistance ,
unable to groom without assistance ,
Additional Notes: _________________________________________________________________
able
unable to get out
unable to toilet without assistance
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Instrumental Activities of Daily Living:
able to do house work with limited or no assistance ,
shop with limited or no assistance ,
able to manage medications with limited or no assistance ,
money with limited or no assistance ,
able to manage
able to prepare meals with limited or no assistance ,
with limited or no assistance ,
assistance ,
able to grocery
unable to do house work without assistance ,
unable to manage medications without assistance ,
able to use the phone
unable to grocery shop without
unable to manage money without assistance ,
unable to prepare meals without assistance ,
unable to use the phone without assistance
Additional Notes: ____________________________________________
Falls Risk Assessment:
last visit ,
fear of falling ,
no frequent falls while walking ,
no fall in the past year ,
no dizziness/vertigo ,
frequent falls while walking ,
injury with fall
Additional Notes: ___________________
Home Safety:
no unsafe flooring hazards ,
appliances ,
working smoke/CO detectors ,
use of seatbelts ,
no unsafe stairs ,
no unsafe gas
no vision or hearing loss while driving ,
has hand bars in the bathroom/shower ,
good lighting in the home ,
unsafe gas appliances ,
protective head gear for biking/high velocity ,
dizziness/vertigo ,
wears protective head gear for biking/high velocity ,
practicing 'safer sex' ,
unsafe flooring hazards ,
no fall since
unsafe stairs ,
no smoke/CO detectors ,
does not use seatbelts ,
vision or hearing loss while driving ,
no fire arms ,
fire arms ,
does not wear
not practicing 'safer sex' ,
does not have hand bars in the bathroom/shower,
poor lighting in the home Additional Notes: _____________________________________________
Glaucoma Screening: (checking pressure in the eyes)
Glaucoma is a condition with elevated eye pressure
I am currently being treated for glaucoma, I had glaucoma screen on _________________, unaware if ever had screened for glaucoma
Pain Evaluation: During the past four weeks have you had bodily pain?
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None
mild
moderate
severe
HOSPITALIZATIONS
Dates
Facility
Reason
Outcome/ Notes
FOR OFFICE USE ONLY
o Initial Preventative Physical
Exam
o Initial annual wellness
visit
Today’s Date
Date of Last Exam
o Subsequent annual wellness
visit
Language or other communication barriers: (Describe)
Interpreter or other accommodations provided today: (describe)
Reviewed above history and findings
o Other